When there is no formal medical director.

Community Hospital has recently experienced events that threaten to dislodge early efforts at obtaining physician involvement in quality improvement efforts.

Everytown USA has a population of 65,000, with a surrounding service area of 235,000 people. Community Hospital is a Trauma Center with 215 licensed beds. The hospital serves as a regional cardiac center providing cardiac cash, angioplasty and stenting, as well as a full service cardiac surgery team performing approximately 350 open heart surgeries per year. The hospital also serves as the regional OB/GYN, pediatric and neurosurgery center.

The hospital has a typical medical staff, but does not have any formal physician-hospital associations such as a medical director or medical affairs officer. Two physicians are interested in improving quality efforts and have begun quality team formations with support from administration. A formal Quality Council and Quality Leadership Council are in place. The first of these continuous quality improvement efforts deals with high loss DRGs involving pneumonia and cardiac cash, followed by bypass surgery.

For the past four years, there has been grumbling concerning the trauma system. Most of the dissatisfaction is from the orthopedic and neurosurgeons, although others are also disgruntled. The hospital trauma designation brings many non-paying patients that appear to negatively impact some physician practices more than others. Approximately six months ago, these upsets culminated in the medical staff voting to change the call system from mandatory to voluntary. In order to accommodate its community mission of supplying all services, the hospital has had to negotiate on-call fees for the orthopedic and neurosurgeons (the general surgeons taking trauma calls have always been paid a stipend). These fees have increased the cost of the trauma center significantly, and are paid for on-call status only--the physicians can also bill for their normal fees, if they actually see a patient.

Non-participating physicians (those other than general, orthopedic, and neurosurgeons) are upset, and have stated that they see no need to try and help the hospital to reduce costs by being involved with quality improvement teams if the hospital is going to use the savings to pay "outrageous" fees to the orthopedic and neurosurgeons. Other physicians believe their contributions to the on-call system should be considered too. A physician board member has warned the medical staff that there are insufficient funds to pay everyone an on-call stipend.

How can the two physicians interested in continuing CQI efforts deal with this dilemma?

Our thanks to Kenneth J. Gorske, MD, MBA of Durham, California for submitting this scenario for your consideration.